U F S T SING EAR MESSAGES AND CARE ACTICS IN S P E UBSTANCE ABUSE REVENTION FFORTS Scare tactics—dramatized messaging designed to shock and frighten—were one of the earliest strategies employed to reduce substance use among youth. This strategy, often featuring horror stories, gruesome images, and graphic messaging intended to elicit fear, initially gained popularity as a response to the drug culture of the 1960’s.1 Though used widely since, studies prove scare tactics ineffective in substance abuse prevention. This document summarizes peer-reviewed research published between 1993 and 2014 on the use of scare tactics and fear messages in health communications to prevent substance abuse. It offers state and community-level prevention planners interested in developing health communications campaigns relevant and timely information on the effectiveness of these approaches, and factors to consider when implementing such efforts. The Fine Print: Search Methods and Criteria for Inclusion To identify the articles contained in this summary, we conducted a thorough search of the databases PSYCHINFO and PUBMED, using the following parameters:  Key words that included substance abuse, prevention, scare tactics, fear messages, fear appeals, threat appeals, and health communications.  Articles published between January 1993 and February 2014. This range of dates was dictated by available resources, as well as the view that more recent reviews would be more relevant for planning current prevention activities. When our search yielded meta-analyses and systematic literature reviews, we consulted these to identify and review individual studies that met the criteria for inclusion. Over 1,000 potential records of individual articles were identified and reviewed for inclusion. We then selected articles for inclusion based on the following criteria:  The full text was available  The article was published in a peer-reviewed journal  The article included clearly identified methodologies and results  The article discussed a study that used U.S. samples 1 Prevention First (2008). Ineffectiveness of Fear Appeals in Youth Alcohol, Tobacco and Other Drug (ATOD) Prevention. Springfield, IL: Prevention First. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. January 25, 2016 http://www.samhsa.gov/capt/ PAGE 1 For each selected article culled from the sources listed above, we distilled the information pertinent to the use of scare tactics in substance abuse prevention efforts. CAVEATS  Most of the published literature in peer-reviewed journals addressing this topic used university student samples and were experimental studies versus studies of actual prevention interventions or programs.  Most of the published literature on scare tactics and fear messages investigated media tactics such as public service announcements. No peer-reviewed research investigating sensationalized or staged events (e.g., mock car crashes, grim reaper events) was identified.  Strategies that remain unpublished in a peer-reviewed journal are not included in this review.  Articles reporting the use of scare tactics and fear appeals messages for health behaviors other than the prevention of substance use (alcohol, illicit drugs, and tobacco) are not included in this review.  The detailed summaries display key, relevant considerations and major findings for included studies. For more detailed information, we encourage you to review the full text articles or to consult with your evaluator. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 2 Detailed Summaries Lee, M. J., & Ferguson, M. A. (2002). Effects of anti-tobacco advertisements based on risk-taking tendencies: Realistic fear vs. vulgar humor. Journalism & Mass Communication Quarterly, 79(4), 945- 963. Participants who were classified as low and high in rebelliousness and low or high in Intervention impulsiveness (based on pre-test answers on a self-report measure) watched one of two (including specific types of anti-smoking advertisements: vulgar humor or realistic fear. They then reported on scare tactics or their perceptions of the ads and smoking related variables. fear messages) It was hypothesized that participants with high rebelliousness would be more affected by the fear ads, and less likely to quit in response to them. Target Population U.S. university students Experimental study using random assignment to one of two groups and one control group; samples from two U.S. universities and a junior college included 223 students, 65 of these were current smokers. Evaluation Design Outcome variables were:  Interest in the ads, smoking health-related perceptions, intention to quit smoking, positive perceptions of smoking.  Manipulation checks were used to confirm reactions to the anti-smoking ads Attitudes about the dangers of smoking were not associated with the type of add seen. Outcomes Participants who were rebellious but low in impulsivity had more intention to quit when they saw the vulgar versus the fear ads. This is a laboratory study with university students that may have limited generalizability to real world conditions or other populations. Few smokers were in each of the categories, which limits the ability to interpret intention to quit data. Limitations This study relies on self-report data, which generally correlates to actual intentions, but rebellious participants may provide less reliable data. The rebellious and impulsive categorizations were somewhat artificial; participants who scored above average were classified as high in these characteristics. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 3 Lee, M. J., & Shin, M. (2011). Fear versus humor: The impact of sensation seeking on physiological, cognitive, and emotional responses to anti-alcohol abuse messages. The Journal of Psychology, 145(2), 73-92. Participants watched 8 30-second anti- drinking and driving PSAs that were categorized by Intervention the type of message: fear or humor. The fear message PSAs included both arrest and physical (including specific injury scenarios. These PSAs were presented in random sequences to each participant. scare tactics or This study investigated the differences in physiological, cognitive, and emotional responses fear messages) to the PSAs. It also investigated the difference in reactions between participants classified as either high or low sensation seekers. Target Population U.S. university students Experimental study with between and within subjects design; sample consisted of 71 college students (43 female, 25 male) with an average age 21. Study monitored participants’ response through heart rate monitors, electrical measurement of facial muscles, and self- Evaluation Design report measures. A manipulation check was used to confirm that the PSAs were associated with fear and humor responses. Neither the fear nor the humor PSAs had any influence on intention to change alcohol use behaviors. High or low sensation seeking also did not have any influence on behavioral Outcomes intention. The fear message PSAs resulted in stronger perceptions of the dangers of drinking and driving and higher interest levels than the humor PSAs. This is a laboratory study with university students that may have limited generalizability to real world conditions or other populations. Limitations The dose strength of PSA viewing used in this study may have been too low to affect behavioral intention. In a real world setting, individuals would ideally be exposed to the PSAs more frequently over weeks and months. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 4 Leshner, G., Bolls, P., & Thomas, E. (2009). Scare'em or disgust'em: The effects of graphic health promotion messages. Health Communication, 24(5), 447-458. Participants watched 24 30-second anti-smoking PSAs from four different categories. PSAs Intervention were categorized by the use of a fear message (low or high) and disgust message (low or (including specific high). Fear messages involved negative physical consequences of tobacco use. Disgust scare tactics or messages showed images know to evoke disgust such as internal organs, wounds, and fear messages) decaying material. Target Population Undergraduate students Experimental study with 2x2 within subjects design; sample of 58 non-smoking undergraduate students. Evaluation Design Participants’ heart rates were monitored while viewing the PSAs as a measure of attention to the PSAs. Recognition exercises were administered post-viewing to test for the encoding of the information in the PSAs. Participants’ heart rates demonstrated increased attention while watching PSAs with high fear and disgust levels compared to PSAs with low levels. However, PSAs that had high levels of both fear and disgust were associated with heart rate patterns that suggest that they were paying less attention. This may indicate high levels of fear plus disgust leads to cognitive Outcomes overload and results in disengagement. Participants had higher recognition of the PSAs with high fear and disgust levels compared to PSAs with low levels. However, PSAs that had high levels of both fear and disgust were associated with lower levels of recognition, suggesting lower levels of encoding. This is a laboratory study with university students that may have limited generalizability to real world conditions or other populations. Limitations Behavioral intention to use tobacco was not measured. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 5 Moscato, S., Black, D. R., Blue, C. L., Mattson, M., Galer-Unti, R. A., & Coster, D. C. (2001). Evaluating a fear appeal message to reduce alcohol use among Greeks. American Journal of Health Behavior, 25(5), 481-491. Prior to a week of festivities associated with high alcohol use at a large U.S. university, a Community Standards panel comprised of university administration, the fraternal organization judicial board, a judge, and representatives from 8 law enforcement agencies Intervention was convened. 1,000 students attended. (including specific scare tactics or A consistent fear appeal message was conveyed that students found intoxicated or using fear messages) alcohol underage will be arrested and prosecuted and that the events would be closely monitored during the week. Students were told that if they chose to drink they should reduce consumption and drink responsibly to remain unnoticed by law enforcement. U.S. university student members of fraternities and sororities Target Population Non-experimental design; random sample, consisting of 224 undergraduate fraternal organization residents. Post-test after the festivities week. Evaluation Design Primary outcomes were: self-reported drinking, arrests, and alcohol sales. 78% of those surveyed reported having heard the fear message, 58% directly at attendance at the panel and 42% secondhand. Participants who reported higher levels of fear associated Outcomes with the message reported drinking less during the week. Arrests were lower this year in comparison to prior years. Alcohol sales remained stable. Variables in this study were not controlled and the study did not include a comparison group. The study relies primarily on self-report data, although this is triangulated with arrest and Limitations alcohol sales data. The article did not discuss how law enforcement activities during the festivities may have enhanced the salience of the fear message. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 6 Paek, H. J., Kim, K., & Hove, T. (2010). Content analysis of antismoking videos on YouTube: message sensation value, message appeals, and their relationships with viewer responses. Health Education Research, 25(6), 1085-1099. Researchers identified and examined 934 anti-smoking video clips on YouTube were Intervention examined for the following characteristics: message sensation value (MSV) and three types of (including specific messages, those that evoke fear, those that evoke social themes (such as peer norms), and scare tactics or those that employ humor. These four characteristics were then linked to YouTube’s fear messages) interactive audience response mechanisms. Target Population YouTube users Non-experimental, content analysis and descriptive study of anti-smoking video clips on YouTube; clips were rated for sensation value and type of message appeal; the different types of clips were then associated with view characteristics: the reach of the clip (how many Evaluation Design times the clip was viewed), viewer engagement (number of comments posted), and viewer preference ratings (using the scale provided by YouTube). Fear appeals were most prevalent (56.8%), followed by humor (15.3%) and social (9.0%). There were significantly fewer humor appeals used for smoking cessation and secondhand smoke clips incorporated more humor. Outcomes Fear appeals seem to capture attention and interest more than social appeals. On the other hand, humor appeals with high message sensation value were viewed less often and received lower ratings. A controlled experimental study may be needed to further investigate attitudinal and behavioral consequences related t0 anti-smoking videos on YouTube. Limitations Sample characteristics are not known. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 7 Santa, A. F., & Cochran, B. N. (2008). Does the impact of anti-drinking and driving public service announcements differ based on message type and viewer characteristics? Journal of Drug Education, 38(2), 109-129. Participants watched 10 30-second anti-drinking and driving PSAs. PSAs that were Intervention categorized by the type of message: empathy, fear, or informational. These PSAs were (including specific presented in random sequences to each participant. scare tactics or fear messages) Target Population U.S. undergraduate students and adult driving under the influence (DUI) offenders Experimental study within subjects design; sample consisted of 137 undergraduate students and 17 participants from a community program for DUI offenders. The main outcomes were Evaluation Design behavioral intentions related to drinking and driving. The empathy message PSAs were rated as most effective, the fear PSAs were second in effectiveness and the informational approach was rated as the least effective. Individuals with more drinking and driving experience reported that the PSAs regardless of Outcomes type were less effective compared to individuals with less or no drinking and driving experience. Individuals with high sensation seeking characteristics perceived the PSAs as less effective, in particular the fear-based PSAs. The results of this study are limited because it is very difficult to isolate any one aspect of a message. Another limitation is that the outcome measure perceived effectiveness may not account for actual behavior change. Limitations Because social desirability scores emerged as predictor in some analyses, it is possible that participants provided the answers they thought were most socially desirable. This study was also limited by its use of self-report to assess past experience with DUI. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 8 Schoenbachler, D. D., & Whittler, T. E. (1996). Adolescent processing of social and physical threat communications. Journal of Advertising, 25(4), 37-54. Participants were shown print public service announcements (PSAs) about the consequences Intervention of illicit drug use in adolescents. The PSAs were developed by an advertising agency and (including specific portrayed low, high, and medium levels of two types of fear messages: social threat (negative scare tactics or social consequences of drug use) and physical threat (injury or death from drug use). fear messages) Participants viewed one type of PSA: either a social or physical threat PSA that was at the low, moderate or high level of threat. Target Population 6th and 7th grade students Experimental design with 371 student participants randomly assigned to one of six Evaluation Design experimental conditions; pre- and post-tests assessed participants’ emotional, cognitive, attitudinal and behavioral intentions to use illicit drugs. Attitudes toward drug use were more negative after viewing the social threat PSA compared to the physical threat PSA. Outcomes Participants who were high in sensation seeking had more negative attitudes toward the PSA and more positive attitudes toward drug use. This study may have limited generalization to real world conditions or different populations. Self-reported attitudes and behavioral intentions to use drugs were used, but actual use was Limitations not tracked or queried. The illicit drug was not named in this study. It is not clear if participants had in mind different types of drugs when answering questions and if this had an effect on their responses. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 9 Schmitt, C. L., & Blass, T. (2008). Fear appeals revisited: Testing a unique anti-smoking film. Current Psychology, 27(2), 145-151. Participants watched one of two versions of an anti-smoking film developed by the American Intervention Lung Association. The high fear arousal condition presented the film about the diagnosis and (including specific physical decline from lung cancer of a high school teacher. The low fear arousal version scare tactics or presented an edited version of the film with the most disturbing sections deleted (such as x- fear messages) rays of tumor-ridden lungs). Participants completed self-report measures after watching the film. Target Population U.S. undergraduate students Participants randomly assigned to watch one of two film versions or to a control group that did not watch the film; sample consisted of 46 non-smoking university students. Evaluation Design Outcomes were: attitudes toward smoking, behavioral intention to abstain, and intention to convince a smoker to quit. A manipulation check of the two film versions revealed that there was no difference in the amount of fear generated between the two films. Outcomes Participants who viewed the film were more likely to abstain from smoking and more likely to convince a smoker to quit than participants who did not watch the film. This is a laboratory study with university students that may have limited generalizability to real world conditions or other populations. Limitations Because the two versions of the film were similar in terms of the fear generated, this study cannot isolate the effects of a fear message. Rather, the outcomes reflect the effects of watching and anti-smoking film. Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS283201200024I/HHSS28342002T. For training use only. November 30, 2015 http://www.samhsa.gov/capt/ PAGE 10